1. Tutorial By
Dr Waqar

2. HOPE YOU ALL HAD A GOOD LUNCH !

3. Questions
About how much c.c. fluid will make ascites detectable by clinical exam?
Name some causes of ascites?
What is SAAG ratio?
If the SAAG ratio is more than 1.1, what are the causes of ascites?
If the SAAG ratio is less than 1.1, what are the causes of ascites?
Name any complication of ascites?

4. Answers
1500 cc
Cirrhosis, CHF, Peritonitis, nephrotic syndrome, Budd Chiari syndrome,Portal HTN
SAAG ratio is : difference between serum albumin & ascitic fluid albumin.Used to classify ascites into either transudate or exudate
Cirrhosis, CHF, portal HTN
Peritonitis, nephrotic syndrome
Spontaneous bacterial peritonitis, respiratory distress, Right pleural effusion

5. Questions
7) Serum albumin is 4 mg, ascitic fluid albumin is 0.5 What is the SAAG ratio? 8) Name some treatments for ascites? 9) Which is the diuretic of first choice to treat ascites? 10)Spontaneous bacterial peritonitis is characterised by how many neutrophils in the ascitic fluid? 11) If the ascitic fluid contains bacteria but neutrophils about 100, can you call this SBP?

6. Answers
7) SAAG ratio is 3.5 8) Low salt & water intake, Diuretics, Paracen- -tesis 9) Spironolactone ( Aldactone) 10) SBP: 250 or more neutrophils/uL 11) No, it is not called SBP. We call SBP only if neutrophil count is > 250 cells/uL

7. Questions
12) A young female taking oral contraceptives, comes with Right upper quadrant pain & ascites since 2 days. What is your suspected diagnosis?

8. Answer 12
BUDD-CHIARI SYNDROME ( risk factors are: high estrogen states like pregnancy & oral contraceptives, hypercoagulable disorders)

9. QUESTIONS
13) Name some causes of Budd Chiari syndrome 14) What treatments are available for Budd Chiari syndrome? 15) Which bacteria cause SBP? 16) A patient with cirrhosis & ascites is doing stable. If he becomes drowsy and ascites worsens, what should you think about? 17) Which antibiotics are used for SBP?

10. Answers
13) Pregnancy, O.C., thrombotic disorders 14) Heparin, warfarin, stent, angioplasty 15) E.Coli, Klebsiella, Pneumococci 16) Think of SBP & do paracentesis to rule it out 17) 3rd generation cephalosporins or cipro ( i.v.)

11. Questions 18)Name some causes of hepatitis?
19)Name any 2 drugs which can cause hepatitis?
20) What is the mode of spread of Hep.A?
21) Can Hep. A cause cirrhosis ?
22) What is the blood test for acute hepA?
23) Who should get Hep A vaccine?

12. Answers
18) Viruses ( A,B,C, EBV), drugs, ischemia to the liver, poisons, alcohol, auoimmune hepatitis 19) Panadol, INH, Halothane gas 20) Fecal-oral route 21) No, it can not cause cirrhosis 22) Anti HAV antibody, IgM type 23) Person going to an endemic area, patient with chronic liver diseases , sewerage workers

13. Questions
24) What is the mode of spread of Hep B? 25) Name the antigens of the Hep B virus? 26) In acute hep B, which antigens can be found in the serum while the patient is symptomatic? 27) After recovery from acute Hep B, which antibodies are found in the serum? 28) Which antigen of the Hep B virus never appears in the serum? 29) Which is the most common mode of transmission for Hep B worldwide?

14. Answers
24) * Vertical (mother to fetus) * Parenteral * Sexual transmission 25) Antigens are : s (surface antigen), e & c 26) “s” antigen & “e” antigen 27) Anti HB“s” , anti HB “e” & anti HB “c” 28) “c” antigen never appears in the serum 29) Vertical transmission

15. Serologic Scenarios
1) “s” antigen present, “e” antigen present since 1 wk. Hep B DNA also present. 2) “s” antigen & “e” antigen present since 8 months & LFTs are high. 3) No “s” antigen, no “e” antigen, but anti “s” antibody present & antiHBc antibody present 4) “s” antigen present for more than 6 months but LFTs are normal.

16. Answers serologic scenarios
Acute hep B
Chronic Hep B
Recovered from Hep B
Carrier state

17. Questions
30) Name the blood tests for diagnosis of Acute Hep B? 31) Name the drugs used to treat chronic hepB? 32) What is the schedule of Hep B vaccination? 33) Patient “1” has hepatitis B with “s” ag. & “e” ag. present. Patient 2 has hep B with only “s” ag present, no “e” ag. Which patient is more infectious to others?

18. Answers
30) Diagnosis of acute hep B: “s” ag, “e” ag, Hep B DNA, Anti HBc ( IgM type) 31) * Interferon * Nucleotide analogues * nucleoside analogues 32) 0, 1 month, 6th month 33) Patient 1 is more infectious ( presence of “e” antigen is highly infectious.)

19. QUESTIONS
34) My friend got a needle stick injury from a hep B patient. He came to me for advice. He told me that he has not received Hep B vaccine in the past. I told him to get the full series of Hep B vaccine & then don’t worry. He will not get HepB. Did I do right or wrong?

20. Answer 34
I was partly wrong. This patient shud first get hep B Immune globulins to immediately kill the virus which got in his blood. Vaccination takes many months to develop immunity. Immune globulins & vaccine can be given on the same day.

21. Questions
35) What are the long term complications of Hep B & C? 36) Is sexual transmission a “common” mode of Hep C transmission? 37) Name the 2 blood tests done for Hep C diagnosis? 38) In a patient with Hep C, can the LFTs be normal ? 39) Name some treatments of Hep C?

22. Answers
35) Cirrhosis ( & its complications), Hepato- -cellular carcinoma( liver cancer) 36) No, sexual transmission is not a common mode of hep C transmission 37) Anti-HCV antibody & Hep C virus levels by PCR test. 38) Yes, LFTs can be normal coz many patients have fluctuating LFTs. One day they are normal & then may be raised another day. 39) Ribavirin, Sofusbivir, Ledipasvir ( RaSuL )

23. Scenario
A person got needle stick injury from a Hep C patient 2 wks ago. He comes to you and & wants to be tested for Hep C. He was negative before this. Which test will you order today?

24. Scenario answer
You should order Hep C levels by PCR. Checking for antibody is useless coz antibody takes about 4 to 6 wks to become positive

25. Question 40
What advice/ counselling should you give to Hep C patients?

26. Answer 40 Don’t donate blood or tissue
Don’t share i.v. needles, razors etc
Avoid alcohol ( otherwise liver will get damaged more)
Get vaccination for HepB & A, if not done already.

27. Questions
41) Which hepatic virus can be very fatal if acquired during pregnancy?

28. Answers
41) Hep E

29. QUESTIONS
42) Name 2 complications of paracentesis? 43) Your friend tells you that his father has Hep D. Which other hepatic virus will the patient surely have? 44) Is hep C a contraindication to pregnancy?

30. Answers
42) Peritonitis, intestinal perforation 43) Hep B. ( hep D can not occur alone) 44) No, it is not a contraindication. We just tell the couple that there is a little risk that the baby will get it. Then, it is up to them to decide.

31. Case 1
A 40 year old man c/o acute pain and swelling in the ankle joint. Name 3 possible diagnoses?

32. Answer case 1
Gout
Pseudogout
Septic arthritis

33. Case 2
What do you see in this X-ray?

34. Answer case 2 Joint destruction Bone erosion Overhanging joint margins
Swelling around the joint

35. QUESTIONS
45) How do the crystals of uric acid appear under the polarised light microscopy? 46) How do the pseudogout crystals appear? 47) Name 3 joints which are commonly affected by CPPD disease? 48) What are the possibilities which can occur with hyperuricemia? 49) Name 2 indications of starting uric acid lowering treatment in gout?

36. Answers
45) Uric acid crystals: negatively birefringent & needle shaped. 46) Pseudogout crystals: positively birefringent 47) Wrist, knee, symphysis pubis 48) Possibilities wth uric acid : Gout (acute or chr.) asymptomatic, renal damage, renal stones 49) Start uric acid lowering therapy if: * More than 2 acute attacks per year * Chronic symptomatic gout * Chronic gout with Tophi * Hyperuricemia causing renal stones

37. Case 3
A known case of gout came to me with acute pain and swelling in the big toe. He is not on any treatment. His uric acid is 10 mg% I started him on NSAID and Allopurinol ( a drug to lower the uric acid). Am I correct?

38. Answer Case 4
I am partially correct. NSAID is O.K. but I shud not give uric acid lowering drugs during an acute attack. Give it after 2 -3 wks.

39. Case 5
What do you se in this X-Ray? What is your diagnosis?

40. Answer case 5
Linear calcification in the knee joint cartilage. Diagnosis: CPPD disease( pseudogout)

41. ?

42. Questions
50) Name any 2 drugs used to treat acute gout? 51) Name any 3 drugs used to lower uric acid levels? 52) Name 3 secondary causes of gout? 53) Most cases of gout are what: primary or secondary? 54) What is tumor lysis syndrome?

43. Answers
56) NSAIDs, Colchicine, Steroids 57) Allopurinol, uricase, probenecid, Febuxostat 58) leukemias, polycythemia, diuretics, 59) Most cases are due to decreased excretion of uric acid of unknown cause ( primary) 60) Tumor Lysis syndrome: When chemo is started for any cancer, excess destruction of cells releases uric acid, K+ and P into the blood, causing hyperuricemia, Hyperkalemia & high P. This can be fatal.

44. Case 6
A patient has chronic gout. His serum uric acid is 10mg% & he has renal stones ( probably uric acid stones). Uric acid in 24 hours urine is very high. You want to start treatment to lower the uric acid level. Which medicine will you start and which will you avoid. Give reasons

45. Answer Case 6
You shud start medicine which inhibits uric acid production ( Allopurinol, Febuxostat, uricase). Don’t start meds which increase uric acid excretion in urine( eg Probenecid) coz it will cause more precipitation of uric acid in the tubules. We don’t want this, coz the patient already has renal stones due to high uric acid in the urine.

46. CASE 7
A 50 year old male travelled from KSA to Australia in a 10 hour flight. Few days later, he developed acute chest pain and shortness of breath. Chest pain was continuous and pleuritic in nature.
BP: 150/ * No fever
Pulse 110, regular
Chest exam: Normal breath sounds, no signs of consolidation, mild pleural rub

47. Questions case 7
Q1) What is your most likely diagnosis? Q2) What is the risk factor in this patient?

48. Answers case 7 Pulmonary embolism
2) Long air travel ( stasis of blood due to prolonged sitting)

49. More Questions about case 7
Name any 3 risk factors for DVT/P.E.?
Name the preferred initial investigation in this patient?
Name some other investigations which are done in these patients?
What treatment will you give to this patient?

50. Answers
Trauma to the legs, Oral contraceptive use, prolonged immobilisation, CHF, pregnancy
Preferred investigaton: CTPA( CT pulmonary angiogram)
V/Q scan, CXRay, Pulmonary angiogram, Doppler ultrasound of the legs, D-dimer levels in blood
* i.v. heparin
* Then oral warfarin or rivaroxaban ( for 3
to 6 months)
* O2, morphine (for pain & anxiety )

51. Question 8
When do we use thrombolytic therapy in P.E.?

52. Answer 8 In massive P.E. when there is: Hypotension/ Shock
Right heart failure due to P.E.( raised JVP)

53. CASE 9
A patient is suspected of having P.E. This is his CXR. What is it showing? What is the cause of the opacity?

54. Answer case 9 CXR is showing “ Hampton’s hump”
It is due to infarction of the lung tissue due to
P.E.

55. Chest Xray
A patient suspected of having P.E. What is this X ray Showing? What is the name of this sign?

56. Answer of X ray
X ray shows hyperlucency ( darkness) in the left upper lung fields due to decreased blood flow ( due to embolism)
This is called WESTERMARK’S SIGN

57. CAN A CXR BE NORMAL IN P.E.?

58. YES ! IT CAN BE NORMAL

59. Case 10
You have a patient with P.E. but you can not give heparin due to some contraindication. What will be your management in that case?

60. Answer case 10
Place an inferior vena cava filter (ivc filter). It will not do anything to the embolus in the lung but it will prevent any further embolus going from the legs to the lungs.